Ethical issues in periviable birth.

Ethics is an essential dimension of the management of periviable birth in both clinical practice and research. The goal of clinical care in periviable birth is to improve outcomes for current pregnant and fetal patients. The goal of research in periviable birth is to improve outcomes for future pregnant patients and fetal patients. This paper provides an ethical framework for professionally responsible clinical management and research to improve the outcomes of periviable birth. The ethical framework is based on the professional responsibility model of obstetric ethics, which rejects rights-based reductionism. This model elaborates the ethical concept of the fetus as a patient in terms of beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetus and emphasizes that the fetus is not a separate patient. Guidance is provided for counseling pregnant women about the management of pregnancies at 22 weeks of well-documented gestation, for which directive counseling in the form recommending non-aggressive obstetric management is ethically justified. At 24 weeks and later of gestation, directive counseling in the form of recommending aggressive obstetric management is ethically justified. For the period between 22 and 24 weeks gestation, non-directive counseling is ethically justified. Guidance is also provided for counseling pregnant women about participation in clinical trials and in innovative intervention for fetal benefit. Non-directive counseling should be strictly followed for both.